Member asks: What is the difference between a chief transformation officer and a chief integration officer?

May 22, 2013

Cabell Jonas, Marketing and Planning Leadership Council

As hospitals and health systems reorganize to provide more coordinated care, they’re tapping key leaders to manage the transition. Although their duties and titles may differ by organization, we have seen two distinct roles emerge.

U.S. News names the 'Best Children's Hospitals'

CHOP tops the 2013-2014 list for pediatric facilities

June 11, 2013

U.S. News & World Report on Tuesday announced its "Best Children's Hospitals" in 10 pediatric specialties and named 10 facilities to its Honor Roll for their performance across several specialties.

The Advisory Board congratulates members named to the U.S. News list. All 10 facilities named to the 2013-2013 Honor Roll are Advisory Board members, as well as 94% of all the hospitals named to the list. Read more.

For the seventh annual rankings, U.S. News assessed the performance of 110 hospitals across each of 10 pediatric specialties: cancer, cardiology and cardiac surgery, diabetes and endocrinology, gastroenterology, neonatology, nephrology, neurology and neurosurgery, orthopedics, pulmonology, and urology.

About 75% of the assessments were based on hard data, such as the availability of critical resources and infection prevention efforts. The remaining 25% of the assessments were based on reputational surveys in which 150 specialists in each of the 10 pediatric specialties identified hospitals where they would send their specialty's sickest patients.

Based on the findings, U.S. News identified the top 50 hospitals in each of the 10 specialties. Altogether, 87 U.S. hospitals made one or more of the lists.

"No argument with CHOP at the top, [b]ut all of the hospitals in our rankings, in and out of the Honor Roll, perform at an exceptionally high level," says U.S. News Health Rankings Editor Avery Comarow (U.S. News release, 6/11; Leonard, U.S. News, 6/11).

Transplant officials decide against emergency change to lung policy

June 11, 2013

U.S. organ transplant officials on Monday unanimously voted against changing an under-age-12 policy for lung transplants, opting instead to create a special appeal and review system for such cases.

Why the officials convened to reconsider the policy

An executive committee of the Organ Procurement and Transplantation Network (OPTN)—which manages the nation's organ-transplant policy—convened for the emergency conference-call meeting just days after the policy—which prohibits children under age 12 from being placed on a waiting list for adult-donated lungs—drew widespread attention from the organ transplant community, congressional lawmakers, and a federal court judge.

Last week, U.S. District Court Judge Michael Baylson in Pennsylvania issued two separate orders to temporarily suspend the policy so that two children with end-stage cystic fibrosis—10-year-old Sarah Murnaghan and 11-year-old Javier Acosta, both of whom are being treated at the Children's Hospital of Philadelphia—can be placed on the adult-donated lung recipient list.

Physicians have said the children are medically eligible for an adult lung, but the current policy prohibits them from receiving one. The policy was developed by OPTN, which works with the United Network for Organ Sharing under contract with HHS.

Earlier last week, HHS Secretary Kathleen Sebelius told a congressional panel that she would not personally intervene in Murnaghan's case, saying medical experts should make such decisions. Murnaghan's parents filed a complaint in federal court arguing that so few pediatric lungs are available and the under-age-12 policy unfairly disqualifies children in situations similar to their daughter's simply because of their age.

Milagros Martinez—Acosta's mother—filed a separate complaint against the policy, one day after Baylson ordered HHS to suspend the policy for Murnaghan. Baylson then issued a restraining order preventing HHS from enforcing the policy for Acosta until a June 14 hearing regarding both families' requests for a broader injunction.

On Monday, the OPTN executive committee heard testimony from several physicians and policy experts who acknowledged the need for a review of the current policy. However, some of them expressed medical and ethical concerns about making abrupt changes on an emergency basis, particularly after judicial intervention, the New York Times reports.

Joshua Sonett, a thoracic surgeon at New York-Presbyterian/Columbia University Medical Center, said, "As a lung transplant surgeon, I don't want lawyers or nonmedical professionals trying to tell us the best way or adjudicating ways to transplant the patients." Sonett noted, "On the other hand, as a patient advocate, I want all the patients to get transplanted in a fair manner," adding, "These children are being disadvantaged in a system that hasn't been revisited in the eight years since it was created."

Some committee members also raised concerns about Baylson's orders, which questioned the existing organ transplant system.

Committee member Alexandra Glazier, of the New England Organ Bank, said that judicial intervention is "not an appropriate approach" to managing organ donation. Glazier added that while a judge's order might be well-intentioned, it would "inevitably fail" to consider the various complex medical and ethical issues that are involved in creating broad national rules.

OPTN to allow for case-by-case review

Following the discussion, the committee voted 14-0 not to recommend immediate changes to OPTN's existing policy. Committee member Steven Webber, a transplant specialist at the Vanderbilt University Medical Center, said, "We did not feel that there was overwhelming compelling evidence" to support changes.

Instead, the panel agreed to amend the policy so that transplant centers can request priority status for children under age 12 to be considered eligible for adult-donated lungs on a case-by-case basis. The special requests would be reviewed and authorized by the national Lung Review Board. The amended policy will be effective until July 2014.

Until then, the committee has commissioned a yearlong review of the current policy for allocating adult-donated lungs to children, with a goal of increasing children's access to more transplants. The committee also has the option of extending the review period (Begos, AP/Yahoo! Health, 6/11; Goodnough, New York Times, 6/10; McCullough, Philadelphia Inquirer, 6/11).

The 'Simple Seven' changes that would cut your stroke risk

Blood pressure is the greatest stroke predictor, researchers say

June 11, 2013

Seven lifestyle changes—including quitting smoking and maintaining a healthy weight—could greatly reduce U.S. residents' stroke risks, according to a study in the journal Stroke.

For the study, University of Vermont researchers assessed the stroke risk of nearly 23,000 U.S. residents over age 45. Each participant's stroke risk was scored from 0 (poor compliance) to 14 (optimal compliance with the American Heart Association's "Life's Simple 7" (LS7) health factors:

In the five years following the initial stroke risk calculations, participants suffered 432 strokes. The researchers found that every one-point increase in their LS7 score decreases the chance that a participant would have a stroke within five years.

Blood pressure was the best predictor of whether a patient would suffer a stroke, researchers say. "Compared to those with poor blood pressure status, those who were ideal had a 60% lower risk of future stroke," lead author Mary Cushman said in a statement.

Meanwhile, participants who did not smoke or quit smoking more than a year before the initial calculations had a 40% lower risk of having a stroke compared to individuals that smoked.

How Kaiser Permanente uses effectiveness data to cut costs

June 11, 2013

The Kaiser Permanente Division of Research has leveraged comparative effectiveness research (CER) to reduce its cancer screening costs and improve detection rates, the San Jose Mercury News reports.

Through health reform, the federal government will spend $3.5 billion through 2019 to determine which drugs, treatments, and medical devices are most effective in terms of patient outcomes and health care costs. Experts say CER has the potential to transform the U.S. health care system, though little funding is spent on it compared to other medical research.

Currently, "Patients and clinicians often are forced to make decisions without good evidence," says Joe Selby, executive director of the Patient-Centered Outcomes Research Institute. Selby used to serve as the director of the Kaiser Permanente Division of Research in Oakland, which now employs 550 workers.

CER changes Kaiser's screening procedures

Kaiser is considered a national leader in CER, according to the San Jose Mercury News. The health system modified its colon cancer screening process after Kaiser-led CER found sigmoidoscopies, which are similar to but less invasive than colonoscopies and cut mortality rates by 60%. However, screening rates never surpassed 45%, in part because patients find the procedures uncomfortable.

Kaiser's CER later showed that a low-cost, mail-in stool test identified more cancers and polyps and had fewer false positives than older stool tests, according to James Allison, an investigator in Kaiser's research division. Screening rates increased after Kaiser began offering the mail-in tests in the mid-2000s, and Kaiser detected 331 cancers among 340,000 stool tests it mailed to Northern California members in 2011.

Three in 20 GI endoscopes are unclean

'Biological dirt' from other patients lingers on many endoscopes

June 11, 2013

'Biological dirt' from other patient's colons lingers on three in twenty endoscopes, increasing the chance of infection from colonoscopies and other endoscopic procedures, according to a study presented at the Association for Professionals in Infection Control and Epidemiology's annual meeting.

For the study, researchers from the 3M Infection Prevention Division examined 275 gastrointestinal endoscopes used at five hospitals nationwide. The study analyzed the tools for levels of adenosine triphosphate—a marker of contamination from organic matter.

The researchers detected "biological dirt" from other patient's bodies on:

30% of duodenoscopes, which are used to examine the biliary or pancreatic ductal system;

24% of gastroscopes, which are used to diagnose the upper part of the gastrointestinal tract; and

3% of colonoscopes, which are used to examine the colon.

Lead author Marco Bommarito said in a statement, "Three out of 20 is an unexpectedly high number of endoscopes failing a cleanliness criterion," adding, "Clearly, we'd like no endoscopes to fail a cleanliness rating."

According to the Los Angeles Times, improperly cleaned surgical tools at hospitals have led to various high-profile disease outbreaks in the last four years, including facilities run by the Veterans Affairs Department.

For example, at least four patients since 2009 tested positive for AIDS after undergoing colonoscopies at VA facilities in Tennessee, Georgia, and Florida. Additionally, an Atlanta outpatient surgery center recently warned 456 clients that they may have been exposed to HIV, as well as hepatitis B and C.

CDC, which released new cleaning and sterilization guidelines in 2008,estimates that approximately 50 million U.S. residents undergo colonoscopies annually. The agency reports that more outbreaks have been linked to unsterile endoscopes than to any other medical instrument (Mohan, Los Angeles Times, 6/7; UPI, 6/8).

Skewed data? Observation stays rise as readmissions drop

Are hospitals improving care—or overusing observation status?

June 11, 2013

Experts say that the 2012 drop in 30-day readmissions for Medicare patients may have more to do with an increase in observation stays than with care improvements, a theory that could undermine the use of readmissions metrics in quality programs.

In 2012, hospitals reported 70,000 fewer 30-day readmissions than expected. The Obama administration widely attributed the decrease to the impact of looming penalties for readmissions.

However, a patient on outpatient observation status is never admitted, which means any return visit to the hospital does not count as a readmission, according to Modern Healthcare. In 2011, CMS data show that Medicare outpatient observation cases rose by 230,000 claims.

"Fundamentally, the question to me is, have we really done a good job of preventing readmissions, or have we just reassigned people who would have been readmitted to a different status?" Harvard professor Ashish Jha told Modern Healthcare.

Experts worry that hospitals may keep patients in outpatient observation status if they are likely to be readmitted or have recently be admitted to avoid readmissions penalties, which CMS began imposing on hospitals last year.

However, Mark Williams—the chief of hospital medicine at Northwestern University Feinberg School of Medicine—says it is unlikely that the nationwide decrease in readmissions was caused by a deliberate effort to avoid readmissions through observation status. "I'm sure there is someone in the U.S. who is doing it, but I've not seen cases of people who are talking about it," Williams says.

Meanwhile, Nancy Foster—vice president for quality and patient safety for the American Hospital Association—says that the increase in observation stays does not negate the important strides that hospitals have made to re-engineer their care processes and avoid preventable readmissions.

"When we get down to the nitty-gritty of a particular set of measures being applied in a particular way, that's when you discover that no measure is perfect," Foster said, adding that "you may be invoking penalties and pressuring hospitals and clinicians to make changes that the science shows are not in the patients' best interest" (Carlson, Modern Healthcare, 6/10 [subscription required]).

How to keep medical helicopter flights safe

Report: Crewing a medical helicopter is the most dangerous U.S. job

June 11, 2013

Data show that medical helicopters are more likely to crash than any other commercial aircraft, but attorney Scott Brooksby says providers can take steps to encourage better safety among pilots and crews.

According to National Transportation Safety Board data, there were only 14 accidents among major air carrier aircrafts in 2010, and none of those accidents were fatal. In that same year, there were 13 helicopter emergency medical services (HEMS) accidents, and seven of them were fatal. According to a University of Chicago report, crewing a medical helicopter is the most dangerous profession in the nation.

"Operating without the benefit of formal flight plans with takeoffs and landings in uncontrolled locations ranging from roads to ball fields to the tops of buildings, the challenges are incredible," Brooksby writes in Modern Healthcare.

Until greater safety requirements are implemented to reduce the number of crashes, Brooksby urges hospital administrators to adopt these strategies:

U.S. abandons efforts to limit Plan B sales

DOJ says it will lift restrictions on two-dose EC products

June 11, 2013

The Department of Justice (DOJ) on Monday said it would comply with a judge's April ruling that the emergency contraceptive (EC) Plan B One-Step be made available without age or point-of-sale restrictions.

A senior White House official said that President Obama remains opposed to over-the-counter (OTC) EC access but that DOJ decided to drop the case after recent setbacks in federal court.

According to the Wall Street Journal, it is unclear when Plan B will be available OTC. Plan B's manufacturer—Teva Pharmaceuticals—declined to comment on Monday, and the process of relabeling the product could take several weeks.

Background

Last week, the 2nd U.S. Circuit Court of Appeals ruled that FDA must make two-pill versions of EC available without age or point-of-sale restrictions while the court considered the government's appeal of a judge's order to drop restrictions on all EC products. The appeals court's ruling did not address age limits on Plan B One-Step—the more widely used, single-dose version of EC—thereby leaving in place FDA's recent decision to lower the age limit for nonprescription sales from 17 to 15.

The appeals case results from U.S. District Judge Edward Korman's ruling in April that FDA must end age and point-of-sale restrictions on all EC products. In May, Korman refused to stay his ruling while the federal government appealed the decision. DOJ then took the case to the appeals court.

Details of DOJ's plan of compliance

In a letter to Korman on Monday, DOJ said FDA "has asked the manufacturer of Plan B One-Step to submit a supplemental application seeking approval of the one-pill product to be made available O.T.C. without any such restrictions," which the agency promised "to approve ... promptly."

According to the New York Times, FDA expects to also receive similar applications from generic EC manufacturers. FDA will consider those applications based on whether it decides to grant Teva market exclusivity.

DOJ said it would not remove restrictions on two-dose EC products, citing concerns about whether young women would know how to use the drug properly. The two-pill versions are a diminishing portion of the market, the Times notes.

UVAMC physicians say that the teenager drank the sodium-rich sauce on a dare, taking in a potentially lethal dose of about 160 to 170 grams of sodium. After slipping into a coma with seizure-like symptoms, doctors diagnosed him with a sodium imbalance condition called "hypernatremia." In severe cases, the condition can cause excess swelling in brain cells, leading to neurological damage or death.

Physicians flushed sodium from the patient's system with a water- and sugar-based solution, pumping 1.5 gallons into his body in just the first half hour of treatment.

The patient's sodium stabilized after about five hours of treatment, and he woke from his coma three days later. His hippocampus showed residual effects from the seizures for several more days, but he showed no signs of the overdose about a month after the incident.

Daily roundup: June 11, 2013

Bite-sized hospital and health industry news

June 11, 2013

California and Nevada: Rawson-Neal Psychiatric Hospital in Las Vegas will retain its accreditation for the time being, despite allegations that the state psychiatric hospital transported patients with mental illnesses to cities in California and other states. The decision was based on a routine survey conducted by the Joint Commission. However, the Commission will revisit the facility within 60 days to determine whether it will be reaccredited, state health officials announced (Reese, Sacramento Bee, 6/7).

Kansas: A team of physicians at the University of Kansas Hospital used surgical superglue to repair an aneurysm "the size of an olive" in the brain of a three-week-old infant, the Kansas City Star reports.Fewer than 20 such procedures have been documented in medical literature, and doctors say it may be the only case where an infant's brain aneurysm was repaired with the glue (Murdock, Kansas City Star/Philadelphia Inquirer, 6/9).

Oregon: The Oregon Senate last Thursday approved a bill aimed at making it more difficult for parents to obtain nonmedical exemptions from vaccinations for their children. The state has the highest rate in the nation of parents refusing vaccines for their kindergartners for nonmedical reasons. Public health officials warn that high numbers of exemptions could lead to a resurgence of vaccine-preventable diseases, such as whooping cough and measles (Gambino, AP/Modern Healthcare, 6/8 [subscription required]).

Texas: A Houston oncologist has been charged with aggravated assault for allegedly poisoning a colleague's coffee with an antifreeze ingredient. The physician was dating the victim, who was hospitalized after he began experiencing central nervous system depression, cardiopulmonary complications, and renal failure. He underwent dialysis and remains in a physician's care, according to KTRK-TV (Shaw, "Good Morning America," ABC News, 6/8).